CERTIFIED CODING SPECIALIST
PRACTICE EXAM #2 WITH VERIFIED
ANSWERS
A y23-year-old yfemale yis yadmitted yfor yvaginal ybleeding yfollowing ya ymiscarriage
ytwo yweeks yprior yto ythis yadmission. yShe yis yafebrile yat ythis ytime yand yis ytreated
ywith yan yaspiration ydilation yand ycurettage. yProducts yof yconception yare yfound.
yWhich yone yof ythe yfollowing yshould ybe ythe yprincipal ydiagnosis? y- ycorrect
yanswers y-O03.1, yDelayed yor yexcessive yhemorrhage yfollowing yincomplete
yspontaneous yabortion
A ypsychiatrist ydocuments ythat ya ypatient yhas ywide ymood yswings yfrom yexcessive
yhappiness yto yloss yenergy yand ycrying. yWhat ycondition yis ysuspected? y- ycorrect
yanswers y-Bipolar ydisorder
A ypatient ywith ya ycephalic ypresentation yanticipating ya yvaginal ydelivery yfailed yto
yprogress. yAfter ymeasurement yof ythe yfetal yhead yand ya ytrail yof yoxycontin, ythe
, ypatient yunderwent ya ycesarean ysection. yWhat ycondition yshould ythe ycoder ysuspect
yand yquery ythe yphysician yabout? y- ycorrect yanswers y-Cephalopelvic ydisproportion
A y45-year-old ywoman yunderwent ya ycarotid ybypass yand yexperienced ya ysignificant
ydrop yin yblood ypressure yduring ythe ysurgery. yThe ydocumentation ysuggested ythe
ypatient ymay yhave yhad ya ymyocardial yinfraction. yIn yaccordance ywith ythe ycoding
yguidelines, ywhat yshould ythe ycoding yprofessional ydo? y- ycorrect yanswers y-Query
ythe yphysician yto ydetermine yfi ythere ywas ya ycompliance yof ysurgery
If ya ypatient's ydischarge ysummary ydoes ynot ycontain ythat yis ydocumented yby ythe
yanesthesiologist yin ya ypostoperative yevaluation yand ythat yis ydiagnosis ywould
yimpact yMS-DRG yassignment, ythe ycoder yshould
y_____________________________________. y- ycorrect yanswers y-Query ythe
yattending yphysician yregarding ythe yclinical ysignificance yof ythat ydiagnosis
A ypatient yrecord yhas ydocumentation yof yesophageal yvarices. yWhat ycondition ymay
ybe yrelated ythat ymay yaffect ycoding? y- ycorrect yanswers y-Liver ydisease
A ypatient yadmitted ywith yacute yabdominal ypain yis yfound yto yhave yappendicitis yand
yhas yan yappendectomy. yThe ypatient yhas ya ylength yof ystay yof ytwo ydays. yWhat
ytype yof ypatient yencounter yis ythis? y- ycorrect yanswers y-Inpatient
A ypatient ywas ytreated yin ythe yemergency ydepartment yfor ya yswollen yknee yand yan
yaspiration yof ythe yjoint ywas yperformed. yThe ypatient ywas ythen ydischarged yhome.
yIt yis yimportant yto ymake ysure ythat ywhich yof ythe yfollowing yare ydocumented yand
ycaptured yfor ybilling ypurposes? y- ycorrect yanswers y-All yservices yprovided yincluding
ydiagnostic yand ytreatment yprocedures, yas ywell yas yphysician yservices
A ypatient yhas ydocumentation yon ythe ydischarge ysummary yof yurosepsis. yThe
ycoding ystaff yqueries ythe yattending yphysician yabout ythe ycondition yand yis yprovided
yfurther yinformation ythat ythe ypatient yhas ysepticemia. yThis yis yin yalignment ywith ythe
ylaboratory ytests yand ymedication ygiven, ybut ythe ydiagnosis yof ysepticemia ywas ynot
ydocumented yby ythe yphysician. yHow yshould ythe yphysician ybe yrequested yto
ydocument ythe ysepticemia? y- ycorrect yanswers y-An yaddendum yto ythe ychart yshould
ybe ywritten
The ycommittee yresponsible yfor ymedical yrecord ycompletion yreports yto ywhich
ymedical ystaff ycommittee? y- ycorrect yanswers y-Medical yExecutive yCommittee
Two yareas yof ydocumentation yin ythe yhealth yrecord ythat yare ysignificant yareas yof
yfocus yof yaccrediting yagencies yare y_________________. y- ycorrect yanswers y-
Timeliness yand ylegibility yof ymedical ydocuments
In yteaching yfacilities ywhere yelectronic ysignatures yare yused yfor yresidents yand
yattending yphysicians y________________________________________. y- ycorrect
yanswers y-Attending yshould ycosign yafter ythe yresident ysigns ythe ydocumentation
PRACTICE EXAM #2 WITH VERIFIED
ANSWERS
A y23-year-old yfemale yis yadmitted yfor yvaginal ybleeding yfollowing ya ymiscarriage
ytwo yweeks yprior yto ythis yadmission. yShe yis yafebrile yat ythis ytime yand yis ytreated
ywith yan yaspiration ydilation yand ycurettage. yProducts yof yconception yare yfound.
yWhich yone yof ythe yfollowing yshould ybe ythe yprincipal ydiagnosis? y- ycorrect
yanswers y-O03.1, yDelayed yor yexcessive yhemorrhage yfollowing yincomplete
yspontaneous yabortion
A ypsychiatrist ydocuments ythat ya ypatient yhas ywide ymood yswings yfrom yexcessive
yhappiness yto yloss yenergy yand ycrying. yWhat ycondition yis ysuspected? y- ycorrect
yanswers y-Bipolar ydisorder
A ypatient ywith ya ycephalic ypresentation yanticipating ya yvaginal ydelivery yfailed yto
yprogress. yAfter ymeasurement yof ythe yfetal yhead yand ya ytrail yof yoxycontin, ythe
, ypatient yunderwent ya ycesarean ysection. yWhat ycondition yshould ythe ycoder ysuspect
yand yquery ythe yphysician yabout? y- ycorrect yanswers y-Cephalopelvic ydisproportion
A y45-year-old ywoman yunderwent ya ycarotid ybypass yand yexperienced ya ysignificant
ydrop yin yblood ypressure yduring ythe ysurgery. yThe ydocumentation ysuggested ythe
ypatient ymay yhave yhad ya ymyocardial yinfraction. yIn yaccordance ywith ythe ycoding
yguidelines, ywhat yshould ythe ycoding yprofessional ydo? y- ycorrect yanswers y-Query
ythe yphysician yto ydetermine yfi ythere ywas ya ycompliance yof ysurgery
If ya ypatient's ydischarge ysummary ydoes ynot ycontain ythat yis ydocumented yby ythe
yanesthesiologist yin ya ypostoperative yevaluation yand ythat yis ydiagnosis ywould
yimpact yMS-DRG yassignment, ythe ycoder yshould
y_____________________________________. y- ycorrect yanswers y-Query ythe
yattending yphysician yregarding ythe yclinical ysignificance yof ythat ydiagnosis
A ypatient yrecord yhas ydocumentation yof yesophageal yvarices. yWhat ycondition ymay
ybe yrelated ythat ymay yaffect ycoding? y- ycorrect yanswers y-Liver ydisease
A ypatient yadmitted ywith yacute yabdominal ypain yis yfound yto yhave yappendicitis yand
yhas yan yappendectomy. yThe ypatient yhas ya ylength yof ystay yof ytwo ydays. yWhat
ytype yof ypatient yencounter yis ythis? y- ycorrect yanswers y-Inpatient
A ypatient ywas ytreated yin ythe yemergency ydepartment yfor ya yswollen yknee yand yan
yaspiration yof ythe yjoint ywas yperformed. yThe ypatient ywas ythen ydischarged yhome.
yIt yis yimportant yto ymake ysure ythat ywhich yof ythe yfollowing yare ydocumented yand
ycaptured yfor ybilling ypurposes? y- ycorrect yanswers y-All yservices yprovided yincluding
ydiagnostic yand ytreatment yprocedures, yas ywell yas yphysician yservices
A ypatient yhas ydocumentation yon ythe ydischarge ysummary yof yurosepsis. yThe
ycoding ystaff yqueries ythe yattending yphysician yabout ythe ycondition yand yis yprovided
yfurther yinformation ythat ythe ypatient yhas ysepticemia. yThis yis yin yalignment ywith ythe
ylaboratory ytests yand ymedication ygiven, ybut ythe ydiagnosis yof ysepticemia ywas ynot
ydocumented yby ythe yphysician. yHow yshould ythe yphysician ybe yrequested yto
ydocument ythe ysepticemia? y- ycorrect yanswers y-An yaddendum yto ythe ychart yshould
ybe ywritten
The ycommittee yresponsible yfor ymedical yrecord ycompletion yreports yto ywhich
ymedical ystaff ycommittee? y- ycorrect yanswers y-Medical yExecutive yCommittee
Two yareas yof ydocumentation yin ythe yhealth yrecord ythat yare ysignificant yareas yof
yfocus yof yaccrediting yagencies yare y_________________. y- ycorrect yanswers y-
Timeliness yand ylegibility yof ymedical ydocuments
In yteaching yfacilities ywhere yelectronic ysignatures yare yused yfor yresidents yand
yattending yphysicians y________________________________________. y- ycorrect
yanswers y-Attending yshould ycosign yafter ythe yresident ysigns ythe ydocumentation
